zzyzx Posted December 15, 2007 Author Share Posted December 15, 2007 I'm really impressed by all the responses so far. Kudos also to the poster who said to put the patient in shock position. I put that in there to trick you guys, and I thought it would be like 50 posts before anyone caught it, but you've proven me wrong! When this scenario was posted on FlightWeb, there was a lot of discussion about if this patient was stable and if he required immediate electrical theraphy. What do you guys think? Someone has already figured out exactly what's going on here (no suprise), but is graciously keeping the answer quiet. I won't reveal anything for a while so that other people will get a chance to give their opinions. Link to comment Share on other sites More sharing options...
mobey Posted December 15, 2007 Share Posted December 15, 2007 hmmm thinking again.... Rate 300 Delta waves Hx of heart problems Digoxin......Has he been on this long? Maybe he should not be! I'd like to change my answer vanna. Link to comment Share on other sites More sharing options...
Dustdevil Posted December 17, 2007 Share Posted December 17, 2007 Man... post a difficult EKG and people run like rats. :? :crickets: Link to comment Share on other sites More sharing options...
medic001918 Posted December 17, 2007 Share Posted December 17, 2007 I'm going with rapid a-fib, with the possibility of WPW. I wouldn't jump to cardizem to treat this one though, with the chance of that WPW being a problem. I'm going to go with Amiodarone or Procainamide. If you're really not sure, you could always start with the electricity. But if he's mentating well and has IV access, I wouldn't want to go that route to start. I would want to know more about his dig. How long has he been on it? Any recent changes to the dosing? When was the last time he saw his doctor for a follow up? Shane NREMT-P Link to comment Share on other sites More sharing options...
zzyzx Posted December 17, 2007 Author Share Posted December 17, 2007 Yes, it's AF + WPW. So....does this make any difference in our decision wether to go for an IV first and push drugs or to go right to cardioversion? I'm thinking that you would go straight to cardioversion because from what I understand WPW is likely to quickly deteriorate into VF. Dust, I'd like to hear your opinion on this especially. Also, have you treated patients with WPW before? I've never had one. How well do they respond to adenosine and amiodarone? Link to comment Share on other sites More sharing options...
p3medic Posted December 17, 2007 Share Posted December 17, 2007 I saw this case on flightweb, so stayed out....I've treated a few pts with WPW, and adenosine worked just fine. There are better drugs these days, however AF in the setting of WPW should be considered a lethal arrythmia, and terminating it quickly is the best course of action, IMHO. Link to comment Share on other sites More sharing options...
Dustdevil Posted December 17, 2007 Share Posted December 17, 2007 Dust, I'd like to hear your opinion on this especially. Also, have you treated patients with WPW before? I've never had one. How well do they respond to adenosine and amiodarone? I have only seen it in the hospital setting, as I have been out of the field pretty much since 12-leads became an EMS standard. I shudder to think of how many WPWs I treated as VT back in the 3 lead days, when we weren't even taught about WPW. :shock: It's a tricky one. In the hospital, with any signs of decompensation, I have seen very little hesitation to go straight to cardioversion. This guy isn't going to get any better on his own. It's not like VT where there is a good possibility he'll just pop out of it spontaneously. And there are so many potential problems with pharmacological interventions in both WPW and dig controlled Afib that there is a lot of reluctance to dick around with it, especially when the patient is obviously going downhill fast. Adenosine sounds like a no-no to me, for the same reason that procainamide would be out. AV conduction is not a factor in WPW, so delaying it is not the answer, and may well present a problem on down the line. If we break the re-entry cycle of the accessory pathy, but the AV is blocked by Adenosine, the heart has few alternative pathways. Then you end up in a ventricular rhythm that isn't much better than the WPW it replaced. Sure, Adenosine has a short half-life, but that time passes very slowly when you are looking at an agonal or asystolic patient. Amio would be a better way to go, for sure, as it has less potential problems associated with it, despite the indefinite half-life. But I'd still probably rather go with cardioversion before Amio in any decompensating patient. You're going to end up there sooner or later anyhow, probably. And the half-life of electricity is a lot more predictable. This is one of those cases where even a lot of physicians would rather a cardiologist make the call for them, as even cardioversion is a risky option in chronic Afib. Truth be told, this decision is probably more often made in the ICU than the ER or the field. Or, at least it should be. Damn fine case though! WPW so often looks so much like VT that I am sure the misdiagnosis rate is huge, and probably results in a needless mortality rate. And the medics never even know they killed somebody. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 19, 2007 Share Posted December 19, 2007 ok, I agree about WPW. But here is my question. is it safe to cardiovert with an irregular rythm. The monitor will not be able to syncronize. How have people been told to deal with these types of problems? Link to comment Share on other sites More sharing options...
flight-lp Posted December 19, 2007 Share Posted December 19, 2007 ok, I agree about WPW. But here is my question. is it safe to cardiovert with an irregular rythm. The monitor will not be able to syncronize. How have people been told to deal with these types of problems? Most newer models will synchronize without issue. In the case it isn't possible, then deliver unsynchronized shocks. I have cardioverted many unstable irregular tachydysrhythmias over the years and have only had to defibrillate twice due to this issue. Link to comment Share on other sites More sharing options...
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